July 1st, 2011

The inventory of terrible things

When American architect Louis Sullivan coined the phrase, “Form follows function” in 1896, he certainly wasn’t thinking about how psychologists would be doing risk assessments more than a century later. Now here we are busily re-defining our functions throughout the spectrum of mental health services and looking for forms to help us categorize the things we consider important in understanding and changing human behavior.

Especially in the realm of inpatient care, psychologists throughout New England, if not the entire nation, are shifting their focus away from doing therapy and toward providing specialized assessments and developing treatment plans to be implemented in the community.

In the process of making this adjustment in my own practice, I have met many interesting people and a few ambitious forms. The people come through our hospital doors from all walks of life. Some arrive voluntarily seeking psychiatric care but most would rather be elsewhere, anywhere but the state hospital. The forms arrive electronically from the Great Beyond to guide us in gathering everything we need to know to understand the factors that predispose the people to do risky, dangerous things. My job is to introduce the people and the forms to one another so that the information on the forms will help hospital staff understand the people. Here’s where I begin to think about the dictum that form follows function and hope that it applies to the questions I am about to ask.

We have forms to guide us in assessing risks for violence, suicide, self-harm, fire setting and inappropriate sexual behavior. One day it occurred to me that they all share the common function of helping us to take inventory of terrible things. First there are the terrible things that can happen to you. Second, we have the terrible things that you may witness happening to someone else. Finally, there are the terrible things we do to ourselves or to others, sometimes under the influence of events in the first two categories. We also categorize these events according to when they occurred, either before or after we turned 18.

The list of terrible things contains items like victim of Physical abuse? Sexual abuse? Unstable parental situation? and, Witness to physical abuse? We ask questions about self-injury, substance abuse, suicide, running away from home, being cruel to animals, setting fires, failing to take prescribed psychiatric medication, rapidly becoming destabilized after discharge from psychiatric care, misusing privileges in the hospital, violating the terms of probation or parole, school failure, truancy, suspensions, expulsions, and of course, symptoms of major mental illness.

Because there are more than enough terrible things to go around, we would not be surprised if everyone we saw claimed a few of them as their own. Even one of these factors would provide enough of a challenge to derail the lives of most people. The real surprise is that so many of our patients have experienced a fairly large number of unfortunate events. This is clear enough from the completed forms with check marks in so many of the boxes. Yet lists are only lists and the form itself distances us from the anguish hidden behind every answer of “yes.”

Still the anguish is there and it comes out in a variety of ways. It lurks behind sullen expressions of mistrust and angry refusals to talk to another representative of a system that is expected to bring only failure and betrayal. Sometimes anguish loses itself in the oblivion of forgetting or denial. Often it escapes into fantasies of great wealth, achievement or power. It flies first class only to be stopped at the arrival gate by another failure or disappointment. Anguish in the robes of grandeur never makes it through passport control.

Yet not all suffering hides its face from our inquiring eyes and probing questions. There are times when a routine item on a familiar form will trigger a heart wrenching response. Inquiring about delusions of grandeur, you ask the new arrival to the hospital if she believes she has a special mission in life. After a reflective pause, she says that she sometimes thinks that she is here to show other people that their lives are not so bad in comparison to hers. There is a well of sadness here that she wants to share but your time is limited. You offer empathy and the promise of helping her use this hospitalization to prepare for the ongoing therapy she will need in the community after discharge.

She can make a good start on her recovery during her time here, perhaps finally discovering the right combination of medications to control the symptoms of her mental illness. Our wide array of psychotherapy groups can provide information and support to help manage emotional distress, addictions, self-injury and other dangerous or troublesome behaviors. You wish you could offer more but someone else is waiting. He has his own list of terrible things and you must begin by taking inventory.

By Alan Bodnar Ph.D.

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